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Emergenze Respiratorie

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Emergenze Respiratorie

  1. 1. IDENTIFICAZIONE DEL RISCHIO CLINICO  INCIDENT REPORTING  EVENTI SENTINELLA  INFORMAZIONE/CONSENSO  CARTELLA CLINICA  LINEE GUIDA
  2. 2. Linee guida Vantaggi Svantaggi • Omogeneità di Riduzione dell'autonomia comportamenti del medico • Trade-off tra  Restrizione del pensiero l'efficienza e l'efficacia delle logico-deduttivo procedure  Comportamenti della • Possibilità di “Medicina Difensiva” confronto statisticamente valido dei dati
  3. 3. IPOTESI DI COLPA PROFESSIONALE ANALISI SITEMATICA DEL CASO  VALUTAZIONE IN BASE ALLE LINEE GUIDA
  4. 4. IDENTIFICAZIONE DI TUTTE LE IPOTESI POSSIBILI SULLA BASE DELLE TEORIE ACCREDITATE Comportamento Comportamento non coerente con le coerente con le linee linee guida guida INADEGUATEZZA VALIDITA' DELL'USO DELL'USO ACCUSATORIO DIFENSIVO
  5. 5. Motivo di invio in ospedale • Patologia  Patologia cardiaca respiratoria acuta • Patologia  Alterazione addominale condizioni generali • Patologia del SN  Traumi-incidenti- ustioni -intossicazioni • Patologia acuta chirurgica  Varie(maltratt.Abuso violenza)
  6. 6. Criteri di ospedalizzazione per patologia respiratoria • CIANOSI PERSISTENTE • STRIDORE A RIPOSO • IRREQUIETEZZA • DIFFICOLTA’ AD ALIMENTARSI • TACHIPNEA * • TACHICARDIA * * In riferimento all’età VALORI NORMALI MEDI PER ETA’ DEI PARAMETRI VITALI A RIPOSO ETA’ FR FC PAS (mm Hg) < 1 ANNO 30 - 40 110 - 160 70 - 90 2- 5 ANNI 20 - 30 95 - 140 80 - 100 6-12 ANNI 15 - 25 80 - 120 90 - 110 > 12 ANNI 15 - 20 60 - 100 100 - 120
  7. 7. SCORE CLINICO LARINGOTRACHEITE PARAMETRI CLINICI 0 1 2 RUMORE NO CON RONCHI RIDOTTO INGRESSO INSPIRATORIO STRIDORE NO INSPIRATORIO IN/ ESPIRATORIO TOSSE NO PIANTO RAUCO ABBAIANTE RIENTRAMENTI / NO / GIUGULO GIUGULO / ED ALITAMENTO PINNE PRESENTE INTERCOSTALI / NASALI NO PRESENTE CIANOSI NO SI IMPORTANTE FC * NORMALE - CAT. 0 CAT. 1 CAT. 2 FR * NORMALE AUMENTATA MOLTO AUMENTATA CAT. 0 CAT. 1 CAT 2 0-1 a FC FR FC FR FC FR * I valori sono < 130 < 40 < 160 < 50 > 160 > 50 raggruppati per età. 1-2 a < 110 < 35 < 130 < 45 > 130 > 45 > 2 a < 100 < 30 < 120 < 40 > 120 > 40
  8. 8. CRITERI DI OSPEDALIZZAZIONE LARINGOTRACHEITE ACUTA SCORE > 10 > 6 IN CASO DI: • INADEGUATA ASSISTENZA DOMICILIARE • ABITAZIONE DISTANTE DALL’OSPEDALE
  9. 9. CRITERI DI OSPEDALIZZAZIONE BRONCHIOLITE • ETA’ < 3 MESI • COMPROMISSIONE CONDIZIONI GENERALI • F R > 70’ • INCAPACITA’ AD ASSUMERE LIQUIDI PER OS • CIANOSI E/O EPISODI DI APNEA • CATEGORIE A RISCHIO * * Patologie preesistenti: cardiopatie congenite, prematurità, fibrosi cistica, IDC, patologia neurologica concomitante, ecc.
  10. 10. CRISI DI ASMA : CRITERI DI OSPEDALIZZAZIONE • PRONUNCIA POCHE PAROLE O PARLA A FATICA • TACHIPNEA *  PALLORE CUTANEO • TACHICARDIA *  INAFFIDABILITA’ DELLA FAMIGLIA • SIBILI IN-ESP/SILENZIO  STORIA DI PRECEDENTI CRISI A RESPIRATORIO RAPIDA INSORGENZA • DISPNEA (IMPEGNO MUSCOLI  ORTOPNEA OBBLIGATA REPIRATORI ACCESSORI) • AGITAZIONE / IRRITABILITA /  MANCATA RISPOSTA ALTERAZIONE COSCIENZA ALL’USO DI BETA STIMOLANTI • CIANOSI  VALORI DI PEF< 70- 60% DEI VALORI MEDI PER L’ETA’ O DEL * in riferimento all’eta’ VALORE PERSONALE MIGLIORE, QUANDO MISURABILE
  11. 11. Patologie neonatali che più frequentemente richiedono il trasporto a destinazioni elettive ➄ Neonato che necessita di assistenza ventilatoria ➄ Neonato O2 dipendente con insufficienza respiratoria ingravescente ➄ Prematurità ➄ Sospette malformazioni congenite letali o gravi ➄ Neonato con sindrome ipossico-ischemica di 2°/3°grado ➄ Neonato con grave compromissione dei parametri vitali (stato di shock, stato di male)
  12. 12. Adattamento neonatale ADATTAMENTO CARDIORESPIRATORIO ADATTAMENTO TERMICO
  13. 13. Indice di Apgar SEGNI CLINICI 0 1 2 ATT. CARDIACA assente <100 >100 ATT.RESPIRAT SPONT. assente debole irr vigorosa con pianto TONO MUSCOLARE assente debole normale ECCITAB. RIFLESSI assente scarsa pianto vivace COLORITO cianosi o tronco completamente pallore roseo roseo con estremità cianot.
  14. 14. Indice di Apgar VALUTAZIONE DEL NEONATO IN SALA PARTO BUON ADATTAMENTO 8-10 90-95% NEONATALE ADATTAMENTO 4-7 5-6% NEONATALE PRECARIO RIANIMAZIONE <=3 0,2-0,5 PRIMARIA SALA PARTO
  15. 15. Indice di Apgar
  16. 16. Adattamento respiratorio • Avvio attivita’ respiratoria • Riassorbimento liquido polmonare • Arrivo aria nei polmoni e costituizione della CFR
  17. 17. Uso dell’ossigeno
  18. 18. Carenza di surfattante
  19. 19. Indicazioni all’impiego di CPAP Quando con FIO2 =0,60 la pO2 arteriosa non riesce a raggiungere i 50 torr si ricorre alla protesi ventilatoria con tecnica di CPAP La CPAP puo’ essere praticata attraverso tubo endotracheale o per mezzo di tubi nasali , che devono essere ripuliti piu’ volte al giorno per assicurarne la pervieta’. E’ utile l’introduzione di un sondino oro- gastrico per decomprimere lo stomaco Le pressioni di fine espirazione (PEEP) consigliate non devono superare i 4-6 cm di H2O La pressione positiva provocata dalla PEEP puo’ ridurre il ritorno venoso. Pertanto il neonato deve esere esaminato per cogliere i segni di una cattiva perfusione periferica. Quando le PEEP vengono ridotte, aumenta il ritorno venoso al cuore e bisogna osservare eventuali sintomi di insufficienza cardiaca congestizia.
  20. 20. Indicazioni all’impiego di ventilazione assistita - pH<7,20 - pCO2 >60 torr - PO2 < 50 torr CON FIO2 = 0,7-1 o CPAP con PEEP DI 8-10 cm H20 - apnee persistenti I parametri variabili nella ventilazione assistita convenzionale sono: -Pressione positiva di inspirazione (PIP non superiori a 30 cm H2O) - Pressione positiva di fine espirazione (PEEP non superiori a 6-8 cm H2O) -Frequenza respiratoria - Rapporto inspirazione espirazione (I/E) -FIO2 I parametri piu’ vicini ad una dinamica ventilaroria fisiologica prevedono : -PIP tra 10 e 12 cm DI H2O -PEEP di 2 cm di H2O - Frequenza respiratoria di 20 atti per minuto -I/E=1:3 -FIO2=0,22
  21. 21. Il diametro interno del tubo varia proporzionalmente al peso del neonato: - PER NEONATI ELBW TUBI DI 2,5 mm DI dm; - PER NEONATI VLBW TUBI DI 3 mm DI dm; - PER NEONATI LBW TUBI DI 3,5 mm DI dm; -PER NEONATI A TERMINE AGA TUBI DI 4 mm DI dm. La posizione ottimale di un tubo endotracheale e’ a circa meta’ della trachea e la profondita’ di introduzione del tubo sara’ approssimetivamente di 7 cm; 8 cm; 9 cm per neonati di peso corrispondente a 1 kg; 2 kg; 3kg
  22. 22. Posizionamento del tubo intratracheale
  23. 23. La scelta del catetere da aspirazione e’ relativa al diametro del tubo : - un tubo di 2,5-3 mm richiede un n.5 fr. - un tubo di 3,5-4 mm richiede un N.8 fr. Per misurare la profondita’ giusta per l’introduzione del catetere va adoperata la tabella ideata da Anderson e Chandra. Il procedimento di aspirazione va eseguito col capo del neonato girato prima da un lato e poi dall’altro per favorire il passaggio del catetere di aspirazione nel bronco principale controlaterale. Prima di ricominciare l’aspirazione col capo volto verso il lato opposto, va ripetuta per intero la procedura di iperventilazione e di istillazione di fisiologica sterile.
  24. 24. E’ sempre indicata la rianimazione?
  25. 25. Emergenze alla nascita
  26. 26. Assistenza al neonato asfittico
  27. 27. Massaggio cardiaco esterno
  28. 28. Sindrome da aspirazione di meconio
  29. 29. Assistenza al neonato con sospetta sindrome da aspirazione di meconio
  30. 30. Emergenze neonatali
  31. 31. Caratteristiche del prematuro
  32. 32. Prematuro ad alto rischio
  33. 33. Prematuro ad alto rischio
  34. 34. Prematuro ad alto rischio
  35. 35. Prematuro ad alto rischio
  36. 36. Prematuro ad alto rischio
  37. 37. Prematuro ad alto rischio
  38. 38. Prematuro ad alto rischio
  39. 39. Prematuro ad alto rischio
  40. 40. Prematuro ad alto rischio
  41. 41. Assistenza al prematuro ad alto rischio
  42. 42. Prematuro estremo
  43. 43. Prematuro estremo
  44. 44. Prematuro estremo
  45. 45. Prematuro estremo
  46. 46. Prematuro estremo
  47. 47. Prematuro estremo
  48. 48. Terapia farmacologica
  49. 49. Le risorse impegnate per migliorare lo stato di salute dei bambini, rappresentano sicuramente un costo per la società, ma anche un investimento per il suo futuro.

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